Eye Infection Not an Accident Under Dismemberment Policy

Eye Infection Not an Accident Under Dismemberment Policy

A fungal infection that led to the loss of an eye is not compensable under an accidental death and dismemberment policy, according to the U.S. Fifth Circuit. In Ramirez v. United of Omaha Life Ins. Co., 16-11660 (5th Cir. 10/6/17), the plaintiff traveled to west Texas for his employer, MS International, Inc. On one of his trips he contracted a fungal infection, coccidiodomycosis, also known as “valley fever,” that resulted in the loss of his right eye. He sought benefits under an accidental death and dismemberment and life insurance policy provided by his employer. The insurer denied the claim because its policy specifically provided that at employee must be “injured as a result of an Accident, and that Injury is independent of Sickness and all other causes” and further that it “will not pay for any loss which … does not result from an Accident.”

The policy defined an “Accident” as “a sudden, unexpected, and unforeseeable event, independent of sickness and all other causes. [An] accident does not include sickness, disease, medical treatment, bacterial or viral infections, regardless of how it was contracted.” “Sickness was further defined as “a disease, disorder or condition which requires treatment by a physician.” The insurer denied the plaintiff’s claim because the loss of the eye did not result from an “Accident” independent of a “Sickness.” The trial court granted summary judgment in favor of the insurer.

The Fifth Circuit upheld the summary judgment, concluding that “under ordinary principles of contract interpretation, a fungal infection such as coccidiodomycosis falls squarely within the definition of ‘Sickness’ and that the loss of an eye as a result of such a fungal infection is not an “Accident’ within the meaning of the policy.” The court noted that the policy did not define the term “disease,” so the word was accorded its common meaning, which the court found included “a deviation from the healthy and normal functioning of the body.”

The plaintiff argued that the policy should cover fungal infections because such an infection is analogous to food poisoning, which is covered by the policy. The plaintiff further argued that fungal infections are unpredictable and require medical attention. The Fifth Circuit dismissed this argument. “However, to construe the accidental death and dismemberment policy as Ramierz urges us to do would mean that the flu, strep throat, fungal pneumonia, and many other bacterial, viral, and fungal infections would also be analogous conditions because they too are unpredictable and require medical care. The ordinary meaning of the policy language provides no support for including fungal infection in the provision that includes accidental food poisoning with the definition of ‘Accident.’”

This decision by the U.S. Fifth Circuit, upholding the lower court’s summary judgment, represents a common sense interpretation of the applicable insurance policy.